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Student Questionnaire
Depression
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What age range do you fall under?
17 and under
18 - 30
31 - 40
41 - 50
50 and over
Clear selection
What is your gender?
Male
Female
Non-binary
Clear selection
What is your ethnicity? (Check all that apply)
Caucausian
Hispanic
African American/African
Middle Eastern
Asian
Pacific Islander
Native American
Other
Are you currently attending San Diego Mesa College ?
YES
NO
Clear selection
How many hours a week do you work per week?
0 - 10 hours
10 - 20 hours
20 - 30 hours
40 hours or more
Clear selection
Do you consider yourself to be an extrovert or introverted?
Extrovert
Introvert
Clear selection
From a range of 1 to 10, how confident are you with yourself?
Low Confidence
1
2
3
4
5
6
7
8
9
10
High Confidence
Clear selection
How many hours of sleep do you average per night?
4 hours or less
5 - 6 hours
6 - 7 hours
8 hours or more
Clear selection
On a scale from 1-5, how important do you think it is to exercise ?
Not Important
1
2
3
4
5
Very Important
Clear selection
How many days per week do you exercise on average?
None
1 - 2 days per week
3 - 4 days per week
5 - 7 days per week
Clear selection
On a scale from 1-5, how healthy do you consider your diet to be?
Not Healthy
1
2
3
4
5
Very healthy
Clear selection
Have you used any of the following drugs? (Check all the apply)
Alcohol
Tobacco-Related Products
Marijuana
Prescription Drugs (Ex. Adderall, Xanax, Percs, Oxycodone, etc.)
Esctasy / Molly
Hallucinogens (LSD, Magic Mushrooms, PCP)
Methamphetamine
Heroin
Have you ever been diagnosed with a psychological disorder? (Check all that apply)
Clinical Depression
Anxiety Disorder
Bipolar Disorder
Dementia
ADHD (Attention-Deficit/Hyperactivity Disorder
Schizophrenia
Obsessive Compulsive Disorder
Post Tramatic Stress Disorder
None
Do you currently or have ever suffered from depression in the past?
YES
NO
Clear selection
Have you ever had suicidal thoughts?
Never
Once - Twice
Three - Four times
Five or more times
Clear selection
Have you ever attempted to commit suicide?
NO
YES
Clear selection
What age range do you fall under?
17 and under
18 - 30
31 - 40
41 - 50
50 and over
Clear selection
What is your gender?
Male
Female
Non-binary
Clear selection
What is your ethnicity? (Check all that apply)
Caucausian
Hispanic
African American/African
Middle Eastern
Asian
Pacific Islander
Native American
Other
Are you currently attending San Diego Mesa College ?
YES
NO
Clear selection
How many hours a week do you work per week?
0 - 10 hours
10 - 20 hours
20 - 30 hours
40 hours or more
Clear selection
Do you consider yourself to be an extrovert or introverted?
Extrovert
Introvert
Clear selection
From a range of 1 to 10, how confident are you with yourself?
Low Confidence
1
2
3
4
5
6
7
8
9
10
High Confidence
Clear selection
How many hours of sleep do you average per night?
4 hours or less
5 - 6 hours
6 - 7 hours
8 hours or more
Clear selection
On a scale from 1-5, how important do you think it is to exercise ?
Not Important
1
2
3
4
5
Very Important
Clear selection
How many days per week do you exercise on average?
None
1 - 2 days per week
3 - 4 days per week
5 - 7 days per week
Clear selection
On a scale from 1-5, how healthy do you consider your diet to be?
Not Healthy
1
2
3
4
5
Very healthy
Clear selection
Have you used any of the following drugs recently? (Check all the apply)
Alcohol
Tobacco-Related Products
Marijuana
Prescription Drugs (Ex. Adderall, Xanax, Percs, Oxycodone, etc.)
Esctasy / Molly
Hallucinogens (LSD, Magic Mushrooms, PCP)
Methamphetamine
Heroin
Have you ever been diagnosed with a psychological disorder? (Check all that apply)
Clinical Depression
Anxiety Disorder
Bipolar Disorder
Dementia
ADHD (Attention-Deficit/Hyperactivity Disorder
Schizophrenia
Obsessive Compulsive Disorder
Post Tramatic Stress Disorder
None
Do you currently or have ever suffered from depression in the past?
YES
NO
Clear selection
Have you ever had suicidal thoughts?
Never
Once - Twice
Three - Four times
Five or more times
Clear selection
Have you ever attempted to commit suicide?
NO
YES
Clear selection
Submit
Clear form
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